Viewpoint: A long-term plan for the NHS: now we need a vision for health, care and wellbeing

Christine Heron has been examining the implications of the NHS Long Term Plan (LTP). In this first of a series of blogs she looks at organisational change.

As part of my work as a writer on health and care, I talk to people in councils and the NHS across the country and write case studies on areas that are doing well. Most areas are making progress on aspects of integrated health and care and prevention and some have manged to pull many of the strands together.

So, the question is, will the LTP support all areas to reach the standard of the best, and the best to get even better? Well, as with all policies there are opportunities and challenges.

There are many helpful measures in the LTP that consolidate significant shifts in how the NHS operates that have been taking place incrementally over the last few years (see LGiU policy briefing on the LTP (members only)). Among these are a recognition of the importance of working with local government to develop place-based approaches, an increased focus on the importance of outcomes over activity and more action on prevention and tackling health inequalities. All these, and more, make a good basis for the vision of place-based health and care.

However, the messages from health and care experts, like the King’s Fund, have been that top-down reorganisations will be counter-productive. The structural measures in the LTP may not be full top-down requirements but there is a new NHS landscape with some major changes taking place including:

Fewer “leaner” and “more strategic” CCGs that will “support providers to partner with local government and other community organisations on population health, service redesign and LTP implementation” – likely to involve single strategic commissioners or mergers.

“Expanded” community health teams based with primary care networks covering populations of 30-50,000 – intuitively these make sense, but it’s a big change for primary care.

Providers to have extensive responsibility for system-wide outcomes and decision-making and are expected to collaborate – probably involving more grouped trusts and mergers.

ICSs across the country by 2021 – local authorities will be members of ICS partnership boards.

Seven new combined NHS England and NHS Improvement regional directorates – how these will operate is largely unknown, but they will no doubt be keen to make their mark.

Along with the inevitable shifting and shunting as the NHS settles into its latest operating structure, there are other implications of the new landscape to be mindful of.

The NHS has an extremely difficult job – carrying out life-critical activity under intense national direction and in the gaze of media and political scrutiny: perhaps because of this, many NHS leaders feel most comfortable in command and control mode. (See, for example, analyses by the Kings Fund and the Nuffield Trust.) Additionally, after nearly twenty years of competition and autonomy, providers are to be required to collaborate through contracts and, possibly, license arrangements. Is this realistic any time soon?

Incoming senior figures, Baroness Harding (Chair of NHS Improvement) and Ian Trenholm (CQC Chief Executive), have identified NHS silos, fiefdoms, and lack of collaboration with partners. (See LGiU Health, Social Care and Public Health Round-up December 2018. ) Of course, these are generalisations – there are also many collaborative NHS leaders involved effective partnerships.

One aspect of the new arrangements that I find it hard to get my head around is the blurring of the distinction between commissioning and providing. I can see that it makes sense for the relatively small number of large providers in the NHS to take more responsibility for system-wide outcomes. There is though a danger that this might result in the most bullish NHS organisations wanting to ‘provide the whole system’ in the name of collaboration – potentially rolling back positive partnerships with weaker partners in the NHS and the voluntary, community and social enterprise (VCSE) sector.

And what happens if outcomes are not met? Who is going to hold ‘super-providers’ to account? There will need to be extremely clever contract arrangements to make this happen. It’s worth noting that plans for the first integrated care provider in Dudley, where there are strong and ambitious partnerships, have been delayed for the third time – until 2020 – apparently because the national contractual model needed to create a new multispeciality community provider is not yet ready.

Of course, local government has no control over how the NHS is organised. But what it can do at local level is work with like-minded partners in the NHS the VCSE sector and beyond to influence the process according to values that define the best of health care and wellbeing, including through:

a social model of care and support based on promoting independence, including taking risks

working to shared outcomes agreed across a place, rather than organisational convenience

achieving value for money by effective commissioning with a mixed economy of providers who bring different experiences and expertise, like working in community settings

listening to and engaging with local citizens so that they take a more active role and influence how services are delivered

supporting disadvantaged groups – people who are homeless, people with long term conditions, families under pressure, carers and many others

working at a neighbourhood level with communities – be they in dispersed rural or deprived inner urban areas.